Treatment of Hepatitis C virus among people who inject drugs at a syringe service program during the COVID-19 response: The potential role of telehealth, medications for opioid use disorder and minimal demands on patients.

BACKGROUND: Healthcare delivery was disrupted during the COVID-19 pandemic, requiring minimized in-person contact between patients and clinicians. During the pandemic, people with opioid use disorder (OUD) were not only at elevated risk for COVID-19, but had markedly reduced access to treatment for OUD, Hepatitis C virus (HCV) and HIV due to recommended decreased in-person visits. METHODS: From March 15-June 15, 2020 at the syringe services program (SSP) in New Haven, Connecticut, USA, a differentiated care model evolved with reduced clinical demands on people who inject drugs (PWID) to ensure screening and treatment for HCV, HIV and OUD, with a focus on HCV treatment. This model involved a single, bundled screening, evaluation, testing (SET) and monitoring strategy for all three conditions, minimal in-person visits, followed by tele-health communication between patients, outreach workers and clinicians. In-person visits occurred only during induction onto methadone and phlebotomy at baseline and phlebotomy 12 weeks post-treatment for HCV to measure sustained virological response (SVR). Patients received supportive texts/calls from outreach workers and clinicians. RESULTS: Overall, 66 actively injecting PWID, all with OUD, underwent bundled laboratory screening; 35 had chronic HCV infection. Participants were 40 years (mean), mostly white (N = 18) men (N = 28) and 12 were unstably housed. Two were lost to-follow-up and 2 were incarcerated, leaving 31 who started pan-genotypic direct-acting antivirals (DAAs). The mean time from referral to initial phlebotomy and initiation of DAAs was 6.9 and 9.9 days, respectively. Fourteen additional patients were newly started on buprenorphine and 6 started on methadone; three and four, respectively, were on treatment at baseline. Overall, 29 (93.5%) PWID who initiated DAAs achieved SVR; among unstably housed persons the SVR was 83.3%. CONCLUSIONS: In response to COVID-19, an innovative differentiated care model for PWID at an SSP evolved that included successful co-treatment for HCV, HIV and OUD using a client-centered approach that reduces treatment demands on patients yet supports ongoing access to evidence-based treatments.

Implications of Increased Access to Buprenorphine for Medical Providers in Rural Areas: A Review of the Literature and Future Directions.

Buprenorphine/Naloxone (Suboxone®) is an efficacious treatment for opioid use disorder (OUD) due to its more convenient dosing, superior safety profile, and decreased incidence of negative side effects when compared to other forms of medications for opioid use disorder (MOUD). In the United States, updated legislation in 2021 entitled, "The Practice Guidelines for the Administration of Buprenorphine for Treating Opioid Use Disorder", released by the Department of Health and Human Services, creates an exemption for the previously required Drug Addiction Treatment Act of 2000 (DATA) waiver for buprenorphine prescribing for clinicians. This legislation was born out of a need for making MOUD more accessible for patients living with OUD as rates of opioid-related deaths in the United States have continued to rise and have increased disproportionately during the time period of the COVID-19 pandemic. This legislation has the potential to improve access to MOUD across all geographic locations, but may have the most profound impact in rural areas where significant disparities and challenges still exist in patients' ability to access buprenorphine. The purpose of this literature review is to 1) examine how MOUD prescribing has changed after previous legislation changes, 2) explore the current state of buprenorphine access for treatment of OUD in rural America, 3) detail existing barriers in patients' ability to access MOUD, and 4) discuss future directions and considerations as a result of new legislation. This literature review found several existing barriers to receiving MOUD such as increasing costs, insufficient education, significant stigma, and the need for more innovative methods of delivery. We also found that there is currently a large opportunity for growth in the number of rural clinicians able to prescribe buprenorphine, particularly in primary care, that may now occur as a result of this new legislation. Overall, this legislation has the potential to have a positive impact on combating OUD, especially in rural areas, and may be a critical step towards ending the current opioid epidemic in the United States as these described barriers are addressed.

Buprenorphine Induction in a Rural Maryland Detention Center During COVID-19: Implementation and Preliminary Outcomes of a Novel Telemedicine Treatment Program for Incarcerated Individuals With Opioid Use Disorder.

Over 10 million individuals pass through U.S. detention centers on an annual basis, with nearly two-thirds meeting criteria for drug dependence/abuse. Despite proven efficacy, treatment with medications for opioid use disorder (MOUD) is underutilized in jail settings-a gap that could be addressed using telemedicine. Here we describe a new program of telemedicine-based clinical provision of new/continuing buprenorphine treatment for individuals detained in a rural jail. Implementation objectives were completed between January and August 2020, and patient encounters were conducted between August 2020 and February 2021. We established (i) telemedicine hardware/software capability; (ii) a screening process; (iii) buprenorphine administration methods; (iv) necessary medical release procedures; (v) telemedicine encounter coordination and medication prescription procedures; and (vi) a research platform. Seven incarcerated patients have been treated, two of whom were referred from community treatment. Patients were mostly male (71%), non-Hispanic White (86%), and averaged 33 years old. All patients tested positive for an opioid upon intake and began/continued buprenorphine treatment in the jail. Average time to first MOUD appointment was 9 days and patients were maintained in treatment an average 21 days. Referrals for continuing community treatment were offered to all patients prior to discharge. We report successful implementation of telemedicine MOUD in a rural detention center, with treatment engagement and initiation occurring prior to the high-risk period of discharge. The fact that this program was launched during the height of the pandemic highlights the flexibility of telemedicine-based buprenorphine treatment. Challenges and obstacles to implementation of buprenorphine treatment in a correctional system are discussed.

COVID-19 Adaptations in the Care of Patients with Opioid Use Disorder: a Survey of California Primary Care Clinics.

BACKGROUND: With the onset of the COVID-19 crisis, many federal agencies relaxed policies regulating opioid use disorder treatment. The impact of these changes has been minimally documented. The abrupt nature of these shifts provides a naturalistic opportunity to examine adaptations for opioid use disorder treatment in primary care. OBJECTIVE: To examine change in medical and behavioral health appointment frequency, visit type, and management of patients with opioid use disorder in response to COVID-19. DESIGN: A 14-item survey queried primary care practices that were enrolled in a medications for opioid use disorder statewide expansion project. Survey content focused on changes in service delivery because of COVID-19. The survey was open for 18 days. PARTICIPANTS: We surveyed 338 clinicians from 57 primary care clinics located in California, including federally qualified health centers and look-alikes. A representative from all 57 clinics (100%) and 118 staff (34.8% of all staff clinicians) participated in the survey. MAIN MEASURES: The survey consisted of seven dimensions of practice: medical visits, behavioral health visits, medication management, urine drug screenings, workflow, perceived patient demand, and staff experience. KEY RESULTS: A total of 52 of 57 (91.2%) primary care clinics reported practice adaptations in response to COVID-19 regulatory changes. Many clinics indicated that both medical (40.4%) and behavioral health visits (53.8%) were now exclusively virtual. Two-thirds (65.4%) of clinics reported increased duration of buprenorphine prescriptions and reduced urine drug screenings (67.3%). The majority (56.1%) of clinics experienced an increase in patient demand for behavioral health services. Over half (56.2%) of clinics described having an easier or unchanged experience retaining patients in care. CONCLUSIONS: Many adaptations in the primary care approach to patients with opioid use disorder may be temporary reactions to COVID-19. Further evaluation of the impact of these adaptations on patient outcomes is needed to determine whether changes should be maintained post-COVID-19.

Telehealth sustains patient engagement in OUD treatment during COVID-19.

The coronavirus disease pandemic of 2019 (COVID-19) has created significant economic and societal burden, with mortality currently exceeding 615,000 and millions of others affected worldwide. For those with opioid use disorder (OUD), however, the impact on this vulnerable population could be even more severe. The objective of this study was to outline our organizational telehealth adaptations that enabled virtual counseling, peer support, groups, and provider care during COVID-19 in one community-based opioid treatment program. We utilized an observational study design during March to June 2020, during the initial peak of COVID-19 in the U.S. After we closed our facility for the first five business days, we rapidly enacted virtual care with telehealth for peer coaching, counseling, groups, and provider visits. While we lost patient volume during the initial weeks, we observed an overall increase in patient engagement over time. Future state and federal policy should focus on maintaining less stringent policies around the use of telehealth, prescribing, and in-person exams for medication for OUD.